Value of Exercise-based Oncology Rehabilitation for Cancer Survivors - - PowerPoint PPT Presentation

▶
value of exercise based oncology rehabilitation for
SMART_READER_LITE
LIVE PREVIEW

Value of Exercise-based Oncology Rehabilitation for Cancer Survivors - - PowerPoint PPT Presentation

Jun 27, 2023 282 likes •603 views

The heart and science of medicine. UVMHealth.org/MedCenter Value of Exercise-based Oncology Rehabilitation for Cancer Survivors Northern New England Clinical Oncology Society Kim Dittus, MD PhD 10/20/19 UVMHealth.org/MedCenter No Financial

slide-1
SLIDE 1

The heart and science of medicine.

UVMHealth.org/MedCenter

Value of Exercise-based Oncology Rehabilitation for Cancer Survivors

Northern New England Clinical Oncology Society Kim Dittus, MD PhD 10/20/19

slide-2
SLIDE 2

UVMHealth.org/MedCenter

No Financial Disclosures

slide-3
SLIDE 3

Physical Activity & Survival: Breast Cancer

  • Nurses Health Study - Evaluated the impact
  • f physical activity on rates breast cancer

recurrence and death

  • Approximately 3000 nurses diagnosed with

Stage I-III breast cancer between 1984 and 1998

  • Collected information about physical activity

at least 2 years after breast cancer diagnosis

Holmes et al. JAMA, 2005

slide-4
SLIDE 4

Physical Activity and Survival: Breast Cancer

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Recurrence * Breast Ca Death Total Death #

<1hr/wk 1-3 hrs 3-5 hrs >5hrs

Holmes, JAMA 2005

slide-5
SLIDE 5

What if you increase Physical Activity after diagnosis?

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Death Breast Ca Death

No Change Increased

Irwin et al 2008

slide-6
SLIDE 6

Physical Activity decreases all cause and cancer specific mortality

  • Breast Cancer
  • Colo-rectal Cancer
  • Prostate Cancer

McTeirnan A et al, 2019

40-50% Relative Risk Reduction

slide-7
SLIDE 7
  • 87.3% without cancer DID NOT meet recommendations
  • f 150 min/week
  • 95.5% cancer survivors DID NOT meet

recommendations

  • Differences by cancer type:

– 17.9% ovarian meeting – 3.8% prostate meeting – 3.7% breast meeting

Physical Activity Among Cancer Survivors: NHANES 2003-’06

Smith et al AM J Transl Res 2011

slide-8
SLIDE 8

Steps to Wellness

Oncology and Hematology Rehabilitation

slide-9
SLIDE 9

Diagnosis Oncologic Therapy Post Therapy Long Term Survivors

Continuum of Cancer Intervention and Oncology Rehab Needs

Restore or improve function Control side effects of cancer/cancer tx Improve strength and fitness Maintain or improve function Control side effects of cancer/cancer tx Prevent Fitness & Strength Loss Phase 1 Phase 2 & 3

Started Here Aug 2011

slide-10
SLIDE 10

Side Effects

  • f Therapy

Physician/Provider Visit Physical Therapy Evaluation Exercise Tolerance Test One-on-one Therapy Other referrals

Process for Participants

slide-11
SLIDE 11

Exercise Tolerance Testing

Subset Receiving an ETT

  • Over age 60
  • Received Chemotherapy
  • Dx of Head/neck or Lung

cancer

slide-12
SLIDE 12

Cancer Survivors Receive

  • PT and MD/Provider evaluation
  • Exercise Tolerance Test
  • A “tailored” aerobic and resistance exercise

program

  • Opportunity to exercise at cardiac rehab site 2

days per week for 12 weeks

  • Education classes on site
  • Weight loss intervention

3 times a year

slide-13
SLIDE 13

Data Collected

  • Physical parameters

– Example: Fitness & Strength

  • Functional Measures

– Example: Balance & Range of Motion

  • Late/lingering symptoms

– Example: Fatigue & Sleep

  • Quality of Life
slide-14
SLIDE 14

Characteristics of Participants

Gender Female 78.2% Male 21.8% Age 60.0 ± 11.7 years (Range: 20-84 yrs) Type of Malignancy Breast 56.1% Prostate 4.9% Lung 4.5% Metastatic 11.7% Time since diagnosis 2.4 ± 4.4 years (Range: 0.2-27 yrs) Time intervals During initial therapy 21.1% Within a year 47.1% 1-3 years 14.5% > 3 years 17.4% Oncologic Intervention Surgery 80.7% Chemotherapy 62.5% Radiation 63.8%

slide-15
SLIDE 15

Sub maximal Aerobic Capacity: 6 Min Walk Test: Female Survivors

100 200 300 400 500 600 700 Post Pre Meters

*

  • 44% Below predicted at baseline
  • 22% Increase in distance

N=433

slide-16
SLIDE 16

Exercise Tolerance Test – Peak VO2 (N=372 Females)

20 40 60 80 100

Very Poor Poor Fair Good Baseline Post

%

71%

Pre Peak V02 = 22.2 ml/kg/min Post Peak V02 = 24.3 ml/kg/min 10.5% improvement

ACSM

slide-17
SLIDE 17

One Repetition Max Strength Testing (N=393 Females)

20 40 60 80 100 120 140 160 180 200 Lower Extremity 1RM Upper Extremity 1RM Pre Post

* *

lbs

* P of < 0.001

28.2% Increase 43.4% Increase

slide-18
SLIDE 18

Why is Strength Important? Leg strength and mortality

Newman A et al, 2006

Quadriceps Strength (N-m) measured by isokinetic dynamometer

Men Adjusted HR = 1.45 Women Adjusted HR = 1.47

slide-19
SLIDE 19

5 10 15 20 25

Depression Anxiety Fatigue

Pre Post

Depression, Anxiety & Fatigue * * * * p of < 0.001

32% Decrease

slide-20
SLIDE 20

Functional Impairment In Cancer Survivors

Sweeney et al JNCI 2006

5 10 15 20 25 30 35

Cant walk 1/2 mile Problems with stairs Unable to prepare meals

No cancer < 2yrs 2-5 yrs > 5yrs

%

N = 2,218 Cancer Survivors

slide-21
SLIDE 21

Outcomes of Older Survivors in Onc Rehab (n=361)

Onc Rehab Population Age >65 yrs Peak VO2 – Very Poor 71.0% 76.1 % 1RM Chest Press 57.9% 67.9% 1RM Leg Press 77.2% 83.9%

Percent of Elderly in Very Poor Categories Functional Measure: 5 Time Sit to Stand ≥ 15 seconds suggests impaired function Baseline Test 24.5% with ≥ 15 sec 5TSTS Post Test 5.2% with ≥ 15 sec 5TSTS

slide-22
SLIDE 22
  • Cost
  • Space
  • Administration Support
  • Time
  • Brick walls

22

Challenges

slide-23
SLIDE 23

23

What opportunities were in place?

  • Provider champion(s)
  • A well equipped location (Cardiac rehabilitation)

at reasonable hours

  • A rehab therapies administrator willing to risk loss
  • f revenue on physical therapy evaluations
  • Start up funds to pay for an exercise trainer and

a little bit of equipment

  • Ability to generate some clinical revenue
  • System of referral
slide-24
SLIDE 24

24

Financial Structure

Clinical Revenue: MD/PA evaluations $40,175 PT Evaluations 26,269 66,443 Donations: + 40,000 $106,443 Expenses: Exercise Trainers $67,586 Scheduler 10,706 Education 7,450 PT Program Admin 15,745 Physician Admin Time 11,102 Non-salary Expenses 2,625 $115,484

slide-25
SLIDE 25

25

Institution Benefits

  • Improved care of cancer survivors
  • Enhanced public image for the medical center
  • Training opportunities
  • Research opportunities
slide-26
SLIDE 26

Oncology Rehabilitation

T1 T2 T3

Translational Research

  • Retrospective studies using the onc rehab database
  • Muscle Biopsy Studies
  • Natural history of the impact of chemotherapy on

cardiovascular/pulmonary and muscle function

  • Behaviorally-based weight loss intervention
  • Use of technology for maintaining exercise
slide-27
SLIDE 27

27

Critical Pieces

  • Physician champion
  • Location
  • Supportive (risk taking?) administration
  • System to capture revenue
  • Some philanthropic support
slide-28
SLIDE 28

Research Collaborators

  • Michael Toth
  • Philip Ades
  • Susan Gilchrist
  • Nancy Gell

Oncology Rehabilitation Staff

  • Patricia O’Brien & Penny Gibson
  • Nate Kokinda
  • Diane Stevens & Jamie LeDuc
  • Rebecca Reynolds & Lucien Benway
  • Kristie Grover

Cardiac Rehabilitation Staff

  • Patrick Savage
  • Jason Rengo

Appreciation to:

28

slide-29
SLIDE 29
  • Holmes MD, Chen WY, Faskanich D, Kroenke C and Colditz GA. Physical Activity and Survival

after Breast Cancer Diagnosis. JAMA 2005;293: 2479-2486.

  • Irwin ML, Smith AW, McTiernan A, Ballard-Barbash R, Cronin K, Gilliland FD, Baumgartner RN,

Baumgartner KB, Bernstein L. Influence of pre- and postdiagnosis physical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study. J Clin Oncol. 2008 Aug 20;26(24):3958-64

  • McTiernan A, Friedenreich CM, Katzmarzyk PT, Powell KE, Macko R, Buchner D, Pescatello LS,

Bloodgood B, Tennant B, Vaux-Bjerke A, George SM, Troiano RP, Piercy KL; 2018 PHYSICAL ACTIVITY GUIDELINES ADVISORY COMMITTEE. Physical Activity in Cancer Prevention and Survival: A Systematic Review. Med Sci Sports Exerc. 2019 Jun;51(6):1252-1261

  • Smith WA, Nolan VG, Robison LL, Hudson MM, Ness KK. Physical activity among cancer

survivors and those with no history of cancer- a report from the National Health and Nutrition Examination Survey 2003-2006. Am J Transl Res. 2011 Aug 15;3(4):342-50

  • Dittus KL, Lakoski SG, Savage PD, Kokinda N, Toth M, Stevens D, Woods K, OʼBrien P, Ades PA

Exercise-Based Oncology Rehabilitation: LEVERAGING THE CARDIAC REHABILITATION

  • MODEL. J Cardiopulm Rehabil Prev. 2015 Mar-Apr;35(2):130-9.
  • Newman AB, Kupelian V, Visser M, Simonsick EM, Goodpaster BH, Kritchevsky SB, Tylavsky

FA, Rubin SM, Harris TB. Strength, but not muscle mass, is associated with mortality in the health, aging and body composition study cohort. J Gerontol A Biol Sci Med Sci. 2006 Jan;61(1):72-77

  • Saeidifard F, Medina-Inojosa JR, West CP, Olson TP, Somers VK, Bonikowske AR, Prokop LJ,

Vinciguerra M, Lopez-Jimenez F. The association of resistance training with mortality: A systematic review and meta-analysis. Eur J Prev Cardiol. 2019 Oct;26(15):1647-1665.

  • Sweeney C, Schmitz KH, Lazovich D, Virnig BA, Wallace RB, Folsom AR. Functional limitations

in elderly female cancer survivors. J Natl Cancer Inst. 2006 Apr 19;98(8):521-9

References

29